CPT 99472E&M

Ped critical care subsq

CPT 99472 covers the physician's work caring for critically ill infants and young children (ages 29 days through 5 years) in intensive care on days after the first day of critical care.

Showing rates for

National Average

Base Medicare rate

$383.63

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

7.99

PE RVU (NF)

3.07

MP RVU

0.8

Total RVU

11.86

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

Loading bundling edits…

Billing tips

Bill only one unit of 99472 per calendar day per patient, regardless of total time spent or number of encounters during that 24-hour period
Impact: Prevents automatic denials from duplicate billing; multiple units per day will be reduced to one unit resulting in refund requests
Verify patient age is 29 days through 5 years (up to 6th birthday); use 99471 for initial day, 99291/99293 for ages 6+, and 99469 for neonates
Impact: Age-inappropriate code use results in 100% denial; correct code selection ensures $383.63 payment versus $0
Document presence of critical illness requiring intensive care unit level services; include specific interventions such as ventilator management, vasopressor titration, or invasive monitoring
Impact: Vague documentation triggers medical necessity denials; specific documentation of critical interventions supports the 11.86 total RVUs assigned to this service
Do not separately bill procedures bundled into critical care (CCI edits include chest x-ray interpretation, blood gases, pulse oximetry, vascular access procedures, gastric intubation, temporary pacing, ventilator management)
Impact: Unbundling triggers NCCI edits resulting in denial of separately billed procedures worth $50-$300; critical care payment already includes these services
Ensure only one physician per group bills 99472 per day; if multiple physicians from same specialty/group see patient, one aggregates and bills for the day
Impact: Multiple physicians from same group billing separately results in denial of all but one claim, creating $383.63 write-off and potential fraud investigation
For Medicare Advantage plans, verify prior authorization requirements as many MA plans require pre-certification for ICU level care beyond 48-72 hours

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 99472 in 2025?

The 2025 Medicare national average reimbursement rate for CPT 99472 is $383.63 for both facility and non-facility settings. This is based on 11.86 total RVUs multiplied by the 2025 conversion factor of 32.3465.

How many times can I bill CPT 99472 per patient?

You can bill CPT 99472 once per calendar day per patient for each subsequent day of pediatric critical care following the initial day (which uses 99471). There is no limit to the number of consecutive days, but only one unit per 24-hour period is allowed regardless of time spent or number of encounters.

What age range is appropriate for billing CPT 99472?

CPT 99472 is specifically for pediatric patients aged 29 days through 5 years (up to the 6th birthday). Use 99469 for neonates 28 days or younger, and use 99291-99292 for children 6 years and older requiring critical care.

What is the difference between CPT 99471 and 99472?

CPT 99471 is for the initial day of pediatric critical care for ages 2-5 years, while 99472 is for each subsequent day. Both cover the same age range and service intensity, but 99471 is billed only once at the start of the critical care episode, and 99472 is used for all following days.

Can I bill procedures separately with CPT 99472?

No, most procedures are bundled into CPT 99472 due to NCCI edits. Bundled services include vascular access procedures, ventilator management, blood gas interpretation, chest x-rays, pulse oximetry, gastric intubation, temporary pacing, and routine monitoring. Only separately identifiable, non-bundled major procedures can be billed with appropriate modifiers.

Do I need to document time for CPT 99472?

No, CPT 99472 is not a time-based code. It is a per-day service that covers all critical care provided during a 24-hour period regardless of total time spent. Documentation should focus on the critical nature of the patient's condition and specific intensive interventions rather than time calculations.

Can multiple physicians from the same group bill 99472 for the same patient on the same day?

No, only one physician per group practice can bill CPT 99472 per patient per day. When multiple physicians from the same specialty group provide care, their services should be combined and billed under one physician's name (typically the attending of record). Separate billing by different groups or distinctly different specialties may be appropriate in specific circumstances.